IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR WASHINGTON COUNTY Small Claims Department ___________________________________ Plaintiff ) ) ) ) ) ) ) ) Case No.____________________________ DECLARATION OF NONCOMPLIANCE AND REQUEST FOR JUDGMENT vs ____________________________________ Defendant Attach a completed Small Claims General Judgment and a copy of the Small Claims Agreement I, (name)________________________________ signed a Small Claims Agreement on (date) ____________ ____________ with (other party's name)_________________________________. A copy of the agreement is attached. (Print other party's name) _________________________________________ has not complied with (followed) the agreement. Explain ____________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ I did not prevent the other party from complying with the agreement. As partial satisfaction of our agreement I have received $ __________________. I request judgment against (name) ____________________________ for $ __________, which total includes: 2. Prejudgment Interest $ 4. Prevailing Party Fee (listed at ORS 20.190 $ Plus Post judgment interest on the amount in section 1 and 2 at the rate set by ORS 82.010(2) (or ___________% by agreement of the parties), and in sections 3 and 4 at the rate set by ORS 82.010(2). Instead of or in addition to a money award, I request judgment for the following terms: ___________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ On (date) ________________, I mailed a copy of this request to the person I request judgment against at (address) _________________________________________________________________________________________________. I hereby declare that the above statements are true to the best of my knowledge and belief, and that I understand they are made for use as evidence in court and I am subject to penalty of perjury. 1. Money Award $ 3. Costs & Service Expenses $ Dated: _________________________ ____________________________________________________ Signature ____________________________________________________ Print Name Form 15.010.1c ­ DECLARATION OF NONCOMPLIANCE AND REQUEST FOR JUDGMENT ­ UTCR 15.010(1)(c) (Revised 8-1-12) American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR WASHINGTON COUNTY Small Claims Department _______________________________ Plaintiff V. _______________________________ _______________________________ Defendant Case No. ____________________________ SMALL CLAIMS JUDGMENT AND MONEY AWARD General Limited Supplemental The court grants judgment for __________________________________("judgment creditor") and against ______________________________________________(" judgment debtor"). In addition to or instead of a money award, the following provisions are ordered: ________________________________________________________________________________ MONEY AWARD 1. Judgment Creditor:_______________________________________________________________ (name, address) Additional information attached, titled "Additional Judgment Creditors" 2. Judgment Debtors Name Address Additional information attached, titled "Additional Judgment Debtors" Year of Birth SSN (last 4 digits) or full tax ID # Driver License # (last 4 digits) & State 3. No person or public body other than Judgment Creditor is entitled to any part of this money award EXCEPT: ___________________________________________________________________________ 4. The total amount awarded by this judgment is $ _______________, which includes: 1. Money Award $ 2. Prejudgment Interest $ 3. Costs & Service Expenses $ 4. Prevailing Party Fee (listed at ORS 20.190) $ Plus Postjudgment interest on the amount in sections 1 and 2 at the rate set by ORS 82.010(2) (or ______% by agreement of the parties), and in sections 3 and 4 at the rate set by ORS 82.010(2) ___________________________ Date _____________________________________________ Circuit Court Judge or Court Clerk _____________________________________________ Print Name Form 15.010.1d ­ SMALL CLAIMS JUDGMENT AND MONEY AWARD ­ UTCR 15.010(1)(d) (Revised 8-1-12) American LegalNet, Inc. www.FormsWorkFlow.com